An article in Current Urology Reports Journal
published in June of 2012 detailed the use of biological grafts in the repair
of pelvic organ prolapse. Specific information is presented in this article
regarding the complications associated with the different prolapse compartments
(posterior, middle and anterior). When the pelvic floor weakens—generally due
to childbirth, surgery, menopause or aging—organs can drop from their normal
position causing significant discomfort, pain and a variety of other symptoms.
There may also be a genetic predisposition which contributes to the development
of pelvic organ prolapse. The authors state that by the age of 80, at least 11%
of all women will require POP surgery.
Unfortunately, there is also a
30% chance of recurrence which will require subsequent surgical procedures.
There are other patient characteristics which can increase the risk of pelvic
organ prolapse as well as surgical failure including obesity, the number of
children, a history of smoking, constipation or a chronic cough and the overall
state of the immune system. To improve the overall results of POP surgery both
biologic and synthetic meshes are used, however synthetic meshes—while
improving anatomic results—can bring complications such as mesh extrusion or
erosion. Biological grafts can offer similarity to recipient tissue, decreasing
the recurrence rate.
Biologic grafts are either
harvested from the patient’s own body from the vaginal lining, the rectum or
the thighs, and while there is no risk of rejection or transmission of disease,
operating times are extended and there can be complications at the site of the
graft. Allografts are grafts which are extracted from cadaver tissue, and while
an overall good choice there is some risk of disease transmission. Xenografts
come primarily from cows and pigs. With both allografts and xenografts, disease
screening is performed and the techniques for harvesting are fairly standard.
The processing techniques can vary, however, with no clear consensus regarding
the best method.
Anterior compartment prolapse
tends to be the most common form of pelvic organ prolapse. Anterior prolapse
occurs when the bladder and/or urethra are protruding; the use of biological
tissue in the repair of this type of prolapse has shown inconclusive results.
Middle compartment prolapse can involve the uterus, bowel, rectum, bladder or
vaginal vault. Comparing biologic grafts to synthetic grafts in the
transvaginal and abdominal repair of middle compartment prolapse has shown
biologic grafts to be inferior to synthetic. Posterior compartment prolapse
involves the herniation of the anterior rectal into the vagina leading to
sexual dysfunction and chronic constipation. While traditional repair of
posterior prolapse has shown high rates of success, painful sexual intercourse can
be a typical side effect.
Regarding biological grafts in
pelvic organ prolapse repairs, the most common complications included graft
erosions which were less serious than the synthetic mesh erosions. The FDA
issued an updated warning in 2011 regarding the use of transvaginal surgical
mesh stating there was insufficient evidence to show any benefits of mesh over
more traditional methods and that mesh complications were “not rare.” Better
patient monitoring following surgery is recommended by the FDA as well as alterations
in the pre-market application approval process.
